105 | How to care for your diabetic cats confidently (and easily!) as a vet nurse
Diabetic patients are some of the most nursing-intensive cases we see… and there are LOTS of ways we can support them.
Today we’re doing another of our evidence-based episodes, where I take some of the newest guidelines out there in vetmed, and turn reading 20-30 page articles into a 20-minute episode you can listen to on the way to the clinic.
In this episode we’re talking about the 2025 iCatCare consensus guidelines on the diagnosis and management of diabetes mellitus in cats.
This is the newest, most up-to-date international guidance, and it’s a big one, because it reflects how feline diabetes management is changing right in front of us. We’ve got more confidence around home monitoring and CGMs, we’ve got clearer guidelines to follow when it comes to diagnosis and follow-up, and we’re also seeing more discussion around using SGLT2 inhibitors for carefully selected cats.
But before we go any further, I want to say something that I think we sometimes forget.
Diabetes is not ‘just insulin’ or ‘just about blood glucose’.
It’s a long-term condition where the caregiver’s ability to cope is genuinely part of the treatment plan (and we’ve got a LOT of evidence that highlights how important this is). And if we want good outcomes, our job as nurses and technicians is to make the plan safe, doable, and sustainable - for our patients, our caregivers, and our practice teams.
So in this episode, that’s what we’re focusing on. I’ll be bringing you the highlights from the guidelines, so you can give better care to your patients, and their families - meaning better outcomes for everyone.
So let’s break this down into the bits that actually matter day-to-day.
Diabetes is one of those things we see all the time… but it isn’t always recognised early.
Diabetes can be deceptively ‘quiet’ at the beginning. Often changes in appetite, urination and water intake are subtle to begin with, and easy to miss - in fact, most of the time when we ask caregivers about it, it’s only in hindsight they realise how long those little changes have been going on.
And because cats are cats, sometimes you don’t realise how dramatic it is until you ask the right questions - which is an area we can (and should!) play a big role in as VNs. History taking is essential, and we’re often a good person to do it, as we are often seen as easier to open up to.
We need to be asking questions like:
Are we seeing genuine PU/PD at home?
Is there weight loss?
What’s the patient’s appetite doing?
What’s their demeanour doing?
Has there been any vomiting, reduced intake, lethargy, or other changes that might make us worry about DKA?
And if we’re concerned (and we’re seeing these patients for something like a senior pet clinic for example) we need to refer them on to the vet ASAP for early diagnosis and treatment.
The guidelines are really clear that diagnosis shouldn’t be made on a single blood glucose reading - particularly important in cats where stress hyperglycaemia is such a common and significant problem.
So rather than focusing on BG alone, we (vets and nurses - because of course VNs are not diagnosing!) are looking for persistent hyperglycaemia that matches the clinical signs, supported by additional evidence like glucosuria, repeat measurements, and elevated fructosamine.
Once the patient has been diagnosed, we need to think about what KIND of diabetic they are.
I’m not talking about ‘type 1’ or ‘type 2’ here, though we know the pathophysiology of feline diabetes differs significantly compared to dogs - with most cats being insulin-resistant, rather than insulin-deficient.
What we actually need to be asking ourselves when nursing a newly-diagnosed diabetic cat is this: is our cat ‘happy’ or ‘unhappy’?
A ‘happy diabetic’ is typically the cat who is:
still eating (often very keenly),
not dehydrated,
not vomiting,
not collapsed,
and not showing red flags for significant ketosis.
An ‘unhappy diabetic’ on the other hand is the one who’s:
off food or picky,
vomiting,
lethargic,
dehydrated,
losing weight rapidly,
or has any sign that we might be heading toward DKA or another serious concurrent illness.
This is essential especially in the wake of newer treatments such as SGLT2 inhibitors - because how we treat each of these patients wil vary. And yes, our vets will be the ones prescribing treatment, but we still need to be aware of the indications and contraindications of each - because we’re the ones nursing these patients, and working with our vets to support their families.
Speaking of treatment, what are the options for our feline diabetics? Which should have insulin, and which need newer treatments?
We have two options when it comes to treating diabetes in cats: insulin, and SGLT2 inhibtors such as velagliflozin (or bexagliflozin, if you’re in the US).
Now we’re not just focused on achieving normoglycaemia here, so while yes, most of our treatment will be managing glucose, we also need to consider things like diet, weight management, and managing concurrent diseases - all of which we’ll chat more about later in this episode.
For now, though, let’s look at insulin.
Insulin works by encouraging cellular uptake of circulating glucose, enabling its use as an energy source and reducing hyperglycaemia. There are many insulin options available, and in general, cats require a longer-acting insulin than dogs.
Perhaps more important than the type of insulin selected, though, is the monitoring and support our patients and their families receive throughout treatment.
Most success or failure early in diabetic management isn’t because a patient is receiving the ‘wrong’ insulin. Often it’s because there are issues with injection technique or timing, we don’t have sufficient data to guide dose changes or we haven’t given doses enough time before adjusting them, or because we’re asking our caregivers to follow unrealistic management steps for them.
The last thing we want is a client at home feeling overwhelmed by their cat’s disease and quietly not coping. And we know from data examining quality of life in diabetic cats (and their families) that this is often the case - a new diabetic diagnosis can be incredibly stressful.
This is where we come in as nurses and technicians, because we’re in a great position to provide support and encouragement.
Our job is making diabetic treatment ‘boring’ or ‘normal’ - keeping it simple, and removing the stress as much as we can. We do this through:
Teaching injection technique,
Checking they’re storing and handling insulin correctly,
Helping them build a routine that works for them,
And making sure they know what ‘urgent’ looks like.
What about SGLT2 inhibitors?
SGLT2 inhibitors are discussed in the guidelines as an option for selected, clinically stable cats. They work by increasing glucose loss in urine, improving clinical signs and glycaemic control without injections - which (and I know this word is overused, but it really does apply here) is a total gamechanger in some households.
However, case selection for SGLT2 inhibitors is essential, and I (and the guidelines) can’t stress this enough. If an inappropriate case is started on an SGLT2 inhibitor, we’re far more likely to see complications.
So if you’re nursing a cat receiving these drugs, your focus needs to be:
making sure screening has been done properly (including ketone assessment),
setting caregiver expectations that we will be checking in early and often,
and being absolutely ruthless about red flags (especially appetite drop, vomiting, dehydration, lethargy).
Because yes, these medications can be brilliant, but they come with a specific risk we need to talk about - and that’s euglycaemic DKA.
So let’s talk about DKA and euglycaemic DKA in feline diabetics.
So we’re all aware of DKA, right - diabetic ketoacidosis, usually an emergency, seriously unwell patient, lots of intensive nursing care required.
Well, with SGLT2 inhibitors, we can see euglycaemic DKA, where the blood glucose might not look ‘high enough’ to panic, but the cat is still ketotic and acidotic.
This is a way of thinking we need to adapt to - because before, DKA has always meant hyperglycaemia. But now, with SGLT2 inhibitors, these drugs will cause glucosuria (and therefore euglycaemia) while ketones can still be present.
This is why ‘the glucose isn’t that high’ should never reassure you if the cat is unwell, and in an SGLT2 inhibitor-treated cat, ANY signs of illness should prompt rapid ketone assessment.
The guidelines highlight the importance of regular and ongoing monitoring in these patients, particularly in the first two weeks of treatment. They also point out that blood beta-hydroxybutyrate rises earlier and urine ketone strips measure different ketone bodies, so blood testing can be more sensitive for early detection.
And if eDKA is suspected in an SGLT2 inhibitor-treated cat, treatment is similar to a ‘normal’ DKA patient. First we need to stop the drug, then we manage fluid balance and electrolyte abnormalities, while providing neutral insulin and IV glucose/dextrose to manage ketosis while preventing hypoglycaemia.
What about monitoring our diabetic cats - what’s the best way to do this?
Another interesting - and perhaps controversial - point the guidelines highlight is this: we need to focus more on clinical signs rather than obsessing over glucose results.
The most important thing - regardless of the treatment our patient is on - is how they are doing clinically. That means ‘how are they?’ not ‘what is their blood glucose?’, and using scoring tools can be a really helpful way for us to quantify this.
The ALIVE diabetes clinical scoring framework is a fantastic tool for us to use when monitoring diabetic cats - and it’s something we can easily build into things like diabetic nurse clinics.
The ALIVE score focuses on things like appetite, weight loss, thirst and urination, and attitude and activity. Each area is scored from 0-3, with 0 being ideal, and 1-3 showing progressive worsening of clinical signs.
And yes, of course we do need to think about glucose monitoring as well (in our insulin-treated cats) but the focus needs to be on both glycaemic control and clinical signs, rather than ‘just’ what the numbers are telling us.
Continuous glucose monitors are a great way to assess glycaemic control - as long as we use them properly.
Glucose monitoring has come a long way over the past few years, and our cats in particular really benefit from this. We know that stress hyperglycaemia massively impacts things like in-hospital curve interpretation, but CGMs have given us an easy, patient-friendly way to assess response to insulin without stress hyperglycaemia interfering with our data.
Veterinary nurses, again, play a vital role in using these devices - from applying them in clinics to advising clients and caregivers on how to use them.
These devices, like any other, have some limitations we need to be aware of. They often don’t read in cats for as long as they do in other species (including humans), and can be less accurate in hypoglycaemic patients - so double-checking low readings with blood glucose is essential.
CGMs are a fantastic way to monitor response to treatment particularly in the early stages, and are typically used intermittently as needed once the patient stabilises (with increased focus on multi-day reports, rather than worrying about single ‘weird’ readings).
These devices have really made a huge difference in the way we monitor and manage our diabetic cats, and are a fantastic route to increasing nursing support for your diabetic patients.
Ok, so that’s treatment and monitoring. But what about feeding our diabetic cats? How should we manage their nutrition?
Diet matters in feline diabetes - moreso than diabetic dogs, actually - and the guidelines support a low carbohydrate approach to help glycaemic control and improve the chance of diabetic remission.
But they’re also realistic about the fact that some cats will NOT eat a diabetic diet (no matter how hard we try), and some households can’t sustain expensive prescription diets. While these diets are ideal, again we need to look at what is a realistic and achievable solution for the individual patient and household, and how can we help with this?
As nurses, this is another area where we are key, because we’re the ones creating feeding plans, advising on things like diet changes, and managing weight loss in our overweight patients (something essential in diabetic cats).
It’s also advisable not to make major diet changes right at the start of initiating treatment. According to the gudielines, our priorities are to stabilise first, then transition to a more appropriate long-term diet. And for SGLT2 inhibitor cats, they mention waiting at least a couple of weeks before dietary change so you can interpret response properly, particularly given that transient GI signs are often seen during the first 1-2 weeks of treatment.
Keeping things simple, practical and realistic is the goal - and as nurses and technicians, our role in this cannot be overstated.
We also need to prepare and plan for hypoglycaemia.
Diabetes is an emotive and stressful disease, and one of the factors that has the biggest impact on caregivers and quality of life is the concern for hypoglycaemia. In fact, the perceived risk of hypoglycaemia often causes more stress to caregivers than the chance of an actual hypoglycaemic event.
Again, this means that education, support, and clear instruction on managing this is vital - and this is an essential part of our role as VNs.
We need to make sure our clients know the clinical signs to look for and the necessary at-home first aid steps, as well as how to manage hypoglycaemia rapidly in the clinic (with things like dextrose boluses/CRIs, and glucagon if needed).
It’s also worth noting that most hypoglycaemic episodes aren’t life-threatening - for example, we often see biochemical hypoglycaemia where the numbers are low but clinical signs are not apparent. And if clinical signs are present, this generally means our insulin dose needs to be decreased.
Interestingly, the guidelines also mention that there’s no evidence for the Somogyi effect in cats, which is a myth that still floats around a lot.
What about diabetic remission - when does it happen, and how can we recognise and manage it?
Remission is one of the most satisfying parts of feline diabetes, but we need to spot it early and manage it appropriately, and that can be hard to do.
Again, it’s another reason why nursing monitoring and ongoing support is so vital in feline diabetes - because signs of remission can be subtle, and we’re ideally placed to help spot them as VNs.
According to the guidelines, signs indicating remission include:
Resolution of clinical signs, combined with:
Normoglycaemia
Normal fructosamine
And negative urine glucose in home samples
If remission is suspected, the insulin dose is reduced in stages, while the patient is carefully monitored.
And as nurses and technicians, we need to be looking out for those subtle signs - decreases in thirst and urination, subtle appetite changes, weight changes, a CGM trace that looks ‘too good’ or caregivers reporting that he’s ‘back to his old self’.
These signs are worth flagging to our vets, because the last thing we want is hypoglycaemia - and by providing ongoing nursing support, we can spot these changes early, and refer these patients on before they deteriorate.
Don’t forget comorbidities - our diabetic cats are usually unstable for a reason!
We’ve already mentioned that our diabetic cats can be challenging to manage, and often there’s far more to their treatment than ‘just’ managing glucose and feeding an appropriate diet.
For our unstable patients, diabetes is often part of a bigger problem - with diseases causing insulin resistance interfering with their diabetic control.
Acromegaly, infection, concurrent steroid use, pancreatitis, obesity and (rarely in cats) hyperadrenocorticism all impact glycaemic control and can destabilise a previously-stable diabetic - so we need to look out for these when monitoring our patients.
That might be looking for worsening clinical signs when seeing these patients for a weight check (despite their insulin dose increasing recently). Or it might be asking targeted questions about things like signs of pancreatitis or urinary tract infection, and referring these patients on to the vet if one is suspected.
Again, looking for those subtle signs - and course-correcting where they are seen - is one of the ways nurses and technicians make a huge difference to these patients.
So what does all of this mean for us, as veterinary nurses and technicians?
Feline diabetes management is not just ‘the vet’s plan’. Yes, they’re prescribing treatment and diagnosing these patients, but they need a LOT of nursing support
We are the ones who:
Identify subtle changes and red flags,
Teach injections and work with caregivers to remove fear,
Set up CGMs and help caregivers use them,
Help build home-monitoring plans that people can actually do,
Keep a close eye on appetite, hydration, weight, demeanour,
And catch things like hypoglycaemia and ketosis early.
And the overarching theme of these guidelines is this: make the patient’s diabetic management plan individualised and achievable - because the best plan is the one that actually happens. And that’s a team effort, from both our vets AND us as nurses and technicians.
The key is to make diabetes care simple - removing the fear, and working with our caregivers as a team with one goal: improve their pet’s (and their own!) quality of life as much as possible.
Please do not underestimate your role in this, because I promise you, there are more ways you can nurse your diabetics than you think.
Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!
Thanks for learning with me this week, and I’ll see you next time!
References and Further Reading
Niessen, S. J. M., Bjornvad, C., Church, D. B., Davison, L., Esteban-Saltiveri, D., Fleeman, L. M., Forcada, Y., Fracassi, F., Gilor, C., Hanson, J., Herrtage, M., Lathan, P., Leal, R. O., Loste, A., Reusch, C., Schermerhorn, T., Stengel, C., Thoresen, S., Thuroczy, J., & ESVE/SCE membership (2022). Agreeing Language in Veterinary Endocrinology (ALIVE): Diabetes mellitus - a modified Delphi-method-based system to create consensus disease definitions. Veterinary journal (London, England : 1997), 289, 105910. https://doi.org/10.1016/j.tvjl.2022.105910
Niessen, S. J., Powney, S., Guitian, J., Niessen, A. P., Pion, P. D., Shaw, J. A., & Church, D. B. (2010). Evaluation of a quality-of-life tool for cats with diabetes mellitus. Journal of veterinary internal medicine, 24(5), 1098–1105. https://doi.org/10.1111/j.1939-1676.2010.0579.x
Taylor, S., Panel Chair, Cannon, M., Church, D., Fleeman, L., Fracassi, F., Gilor, C., Mott, J., & Niessen, S. (2025). iCatCare 2025 consensus guidelines on the diagnosis and management of diabetes mellitus in cats. Journal of feline medicine and surgery, 27(11), 1098612X251399103. https://doi.org/10.1177/1098612X251399103
